This chapter provides an overview of the CPT Surgery section and covers its guidelines. The chapter also focuses on the CPT Surgery General and Integumentary System subsections.
Define key terms.
Explain the organization, format, and content of the CPT Surgery section. Interpret CPT surgery section guidelines and modifiers.
Interpret CPT surgery coding notes for the General and Integumentary System subsections. Assign CPT surgery codes from the General and Integumentary System subsections. Add CPT and/or HCPCS level II modifiers to codes as appropriate.
Surgery Section Organization
The Surgery section is the largest section in CPT and its subsections are organized anatomically. Selecting the appropriate surgery code requires a careful review of the patient record to determine the procedures and services provided. The basic organization of the Surgery section is by major body system, with headings and subheadings based on anatomic site and/or type of procedure.
The CPT Surgical Package Definition
See pages 481-482 of the 3-2-1 Code It! text; What services are always included? Read the Surgery Guidelines at the beginning of the Surgery Section in the CPT code book.
If services are provided by more than one physician, what modifiers do you use? When do you use them? Read about unusual services and treatments. What is the modifier to show unusual services? When do you use it? Find the modifier for a separate procedure. What is the definition of separate procedure? What modifier would you use to show a distinct procedural service?
Integumentary procedures include incision, biopsy removal, paring/curettement, shaving, destruction, excision, repair, adjacent tissue rearrangements, grafts, flaps, and specialized services. Refer to the definitions of surgical terms in the textbook.